report to: public board of directors agenda item: 10 date

Report to: Public Board of Directors Agenda item: 10 Date of Meeting: 30 September 2015

Title of Report: The Report of the Morecambe Bay Investigation Status: For Information Board Sponsor: Helen Blanchard, Director of Nursing and Midwifery Author: Vicky Tinsley, Head of Nursing and Midwifery Appendices Appendix A: RUH self-assessment against the

Morecambe Bay recommendations Appendix B: RUH Improvement Plan for the Morecambe Bay Recommendations

1. Executive Summary of the Report The report provides the Board of Directors with an overview of the Department of Health investigation into Morecambe Bay 2015, undertaken by Dr Bill Kirkup.

2. Recommendations (Note, Approve, Discuss) The Board of Directors are asked to note the recommendations and the report, the self-assessment and the action plan.

3. Legal / Regulatory Implications Reference the new CQC Fundamental Standards - Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3).

4. Risk (Threats or opportunities, link to a risk on the Risk Register, Board Assurance Framework etc)

Risks to reputation of the RUH. A failure to demonstrate sustained quality improvements could risk the Trusts registration with the Care Quality Commission.

5. Resources Implications (Financial / staffing)

6. Equality and Diversity Ensures compliance with the Equality Delivery System.

7. References to previous reports For investigation reports concerning the University Hospitals of Morecambe Bay NHS Foundation Trust (2014).

8. Freedom of Information Public.

Author : Vicky Tinsley, Head of Nursing and Midwifery Document Approved by: Helen Blanchard, Director of Nursing & Midwifery

Date: September 2015

Agenda item: 10 of 26

The Report of the Morecambe Bay Investigation




1. Introduction

This report provides a high level summary of The Report of the Morecambe Bay. It identifies themes and includes recommendations.

2. Executive Summary This independent report, commissioned by the Department of Health and written by Dr Bill Kirkup, investigates failings in maternity care at Furness General Hospital (FGH) covering the period of the 1st January 2004 to 30 June 2013. It sets out at least seven missed opportunities at “almost every level” which meant poor clinical care was not investigated and led to the preventable deaths of one mother and 11 babies. The report makes a series of recommendations, for both the University Hospitals of Morecambe Bay NHS Foundation Trust and the wider NHS, to prevent such failings happening in future. The Investigation Panel included expert advisors in midwifery, obstetrics, paediatrics, nursing, management, governance and ethics. 15,280 documents were reviewed from 22 organisations, and 118 individuals were interviewed between May 2014 and February 2015. Family members of those harmed were invited to attend interviews and Panel meetings as observers.

The report gives a detailed explanation of the development of the issues at Morecambe Bay, dating back to 2004. Kirkup stresses that “no blame should be attached to staff who make mistakes” but notes that improper investigation of incidents between 2004 and 2007 led to a failure to identify underlying problems. He describes the root causes of the dysfunction in the maternity unit at FGH as substandard clinical competence, poor working relationships, a move amongst midwives to “pursue natural childbirth ‘at any cost’”, failures in risk assessment and care planning, and deficient response to adverse incidents. There was no attempt made to escalate knowledge to the level of trust executives and the board following investigations. The report states several interviewees admitted at that time, relationships between midwives, obstetricians and paediatricians were fractured. The report states the experienced clinicians amongst them must have known that this was both unsatisfactory and dangerous. Relations between obstetricians and paediatricians were poor and there were examples of obstetricians proceeding to deliver high-risk mothers in FGH against paediatric advice.




There were five reported incidents during 2008 concerning neonatal, maternity and gynaecological services at Furness General Hospital, Barrow. These included two neonatal deaths (Baby T and Baby B), two maternal deaths and one unexpected death after routine gynaecological surgery. Maternity and neonatal services had their management arrangements changed six times during the period covered by this review. Although some of the incidents involved outcomes that would be regarded seriously in any maternity unit, including maternal deaths, intrapartum stillbirths and neonatal deaths of apparently healthy term babies, the overall approach to investigating and learning lessons could only be described as rudimentary and flawed, the report states.

3. The Findings The findings are stark, and catalogue a series of failures at almost every level – from the maternity unit to those responsible for regulating and monitoring the Trust. The nature of these problems is serious and shocking, and it is important for the lessons of these events to be learnt and acted upon, not only to improve the safety of maternity services, but also to reduce risk elsewhere in NHS systems. There is no doubt that these factors together led to the unnecessary deaths of mothers and babies. There was a systematic failure at all levels

• Poor risk assessment of women - midwife desire for natural birth at any cost e.g. no trigger lists

• Poor working relationship between medical staff and midwives • Lack of training /competencies • Lack of Governance structures • Lack of robust investigation or learning from incidents • No memory from one incident to the next • Lack of candour – e.g. collaboration in statements and defensive response • Little engagement from Executive clinical leads • Loss of medical records / or key documents • Failure of external agencies • The investigation report details 20 instances of significant failures of care in the

FGH maternity unit which may have contributed to the deaths of 3 mothers and 16 babies

Different clinical care in these cases would have been expected to prevent the death of 1 mother and 11 babies. This is almost 4 times the frequency of such occurrences at the Trust’s other main maternity unit, at the Royal Lancaster




Infirmary. The report says the maternity department at FGH was dysfunctional with serious problems in 6 main areas:

1) Clinical competence of a proportion of staff fell significantly below the standard

for a safe, effective service: essential knowledge was lacking, guidelines not followed and warning signs in pregnancy were sometimes not recognised or acted on appropriately. There were poor working relationships between midwives, obstetricians and paediatricians: there was a ‘them and us’ culture and poor communication hampered clinical care

2) Midwifery care became strongly influenced by a small number of dominant

midwives whose ‘over-zealous’ pursuit of natural childbirth ‘at any cost’ led at times to unsafe care. There were failures of risk assessment and care planning resulted in inappropriate and unsafe care

3) There was a grossly deficient response from unit clinicians to serious incidents

With repeated failure to investigate properly and learn lessons; The report says proper investigations into serious incidents as far back as 2004 would have raised the alarm. It was not until 5 serious incidents occurred in 2008 that the reality began to emerge.

4) Neonatal paediatrics services at FGH were staffed and equipped to provide a

restricted range of neonatal care, but not to deal with more pre- term babies who needed more intensive forms of care.

5) Clinical risk assessment and effective planning are crucial if patient harm is to

be avoided. However, the report found there were many examples of the presumption of normality, with failure to recognise or acknowledge high-risk obstetric patients or to recognise when risk status changed; failure to monitor, review and update clinical management plans for high-risk obstetric patients; failure to transfer high-risk mothers to tertiary-level units for delivery; and failure to transfer high-risk neonates to a regional intensive care unit before further clinical deterioration.

6) Although some of the incidents involved outcomes that would be regarded

seriously in any maternity unit, including maternal deaths, intrapartum stillbirths and neonatal deaths of apparently healthy term babies, the overall approach to investigating and learning lessons could only be described as rudimentary and flawed, the report states




4. Recommendations The report recommends a series of wide ranging actions to improve the maternity services. These include: formal admission of the extent and nature of problems; a review of skills, knowledge and competencies of maternity staff and plans to deliver training and development; measures to promote multi-disciplinary team working; a new protocol for risk assessment in maternity services; an audit of maternity and paediatric services; a new recruitment and retention strategy; development of better joint working between hospital sites; exploring links with a partner trust; a programme to raise awareness of incident reporting; a review of incident investigation and responding to complaints; continued work on clinical governance; ensuring managers are clear on roles and responsibilities for quality; and improvements to the FGH delivery suite. These should be delivered with the involvement of CCGs, the CQC and Monitor.

There were 18 recommendations that were made for the University Hospitals of Morecambe Bay NHS Foundation Trust. Further recommendations were made for the wider NHS. A self-assessment has been carried out against these 18 recommendations for the RUH. Each recommendation has been RAG (Red, Amber, and Green) rated to indicate whether the RUH meets the recommendation and if any improvement actions are required. The completed self-assessment is shown in Appendix A. Recommendations RAG rated as “Red” or “Amber”, indicate that improvement actions are required to address potential gaps in practise and meet the recommendations outlined in the report. An improvement plan has been drawn up to identify the improvement actions that will be taken for these recommendations.

The Women and Children’s Division has RAG rated all 18 recommendations and rated 4 green and 4 as amber status. The 4 amber recommendations have been included in an improvement plan, see Appendix B.

5. Conclusion This Report details a distressing chain of events that began with serious failures of clinical care in the maternity unit at Furness General Hospital, part of what became the University Hospitals of Morecambe Bay NHS Foundation Trust. The result was avoidable harm to mothers and babies, including tragic and unnecessary deaths. What followed was a pattern of failure to recognise the nature and severity of the problem, with, in some cases, denial that any problem existed, and a series of missed opportunities to intervene that involved almost every level of the NHS. Had any of those opportunities been taken, the sequence of failures of care and




unnecessary deaths could have been broken. As it is, they were still occurring after 2012, eight years after the initial warning event, and over four years after the dysfunctional nature of the unit should have become obvious. Whilst the recommendations are specific for Morecambe Bay the divisional management teams considered it appropriate to self-assess against these recommendations. The Board of Directors are asked to note the content of the report.




Appendix A: RUH self-assessment against the Morecambe Bay recommendations

No Recommendation RAG Rating

Evidence to support RAG rating / Summary of RUH practice

1. University Hospitals of Morecambe Bay NHS Foundation Trust should formally admit the extent and nature of the problems that have previously occurred, and should apologise to those patients and relatives affected, not only for the avoidable damage caused but also for the length of time it has taken to bring them to light and the previous failures to act.

Green - All complaints and investigations have a named professional to support them through the investigation process. All complaint response letters signed by members of the executive team. Investigations are undertaken with an agreed time period and responses provided.

- There is ongoing monitoring via a central database of contacts to ensure families are kept fully involved.

- Following a serious incident a letter of apology would be sent to the family.

2. University Hospitals of Morecambe Bay NHS Foundation Trust should review the skills, knowledge, competencies and professional duties of care of all obstetric, paediatric, midwifery and neonatal nursing staff, and other staff caring for critically ill patients in anaesthetics and intensive and high dependency care, against all relevant guidance from professional and regulatory bodies.

Amber - STAR system collects and reports training relevant to these standards - Neonatal nursing staff competencies are recorded and repeated on an

annual basis - Midwifery staff competencies recorded on database. Frequency of

updating dictated by maternity training needs analysis supported by the Deanery.

- Medical Trainees recorded in educational supervision through the Deanery.

- Consultants training recorded on STAR and in yearly appraisal. - Processes for monitoring local data collection systems in each speciality

in place - Obstetric Consultants and Registrars to attend PROMPT mandatory

training on an annual basis.







- Detailed Training compliance is formally reviewed at Divisional Board and Performance reviews.

3. University Hospitals of Morecambe Bay NHS Foundation Trust NHS Foundation Trusts should draw up plans to deliver the training and development of staff identified as a result of the review of maternity, neonatal and other staff, and should identify opportunities to broaden staff experience in other units, including by secondment and by supernumerary practice.

Amber - There is a training need analysis completed on an annual basis. Staff are transfer/rotate to other areas across the service so there is clear rotation between areas and broadening of skills.

- The uptake of mandatory training is monitored on a monthly basis via the STAR training.

4. Following completion of additional training or experience where necessary, University Hospitals of Morecambe Bay NHS Foundation Trust NHS Foundation Trusts should identify requirements for continuing professional development of staff and link this explicitly with professional requirements including revalidation.

Amber - Plans are in place for nursing and midwifery revalidation via the lead nurse.

- Annual appraisal is in place, where personal /professional development is discussed and agreed.

5. University Hospitals of Morecambe Bay Green - The operational training team is multi-professional working on various projects which develops an effective multidisciplinary team, projects







NHS Foundation Trust NHS Foundation Trusts should identify and develop measures that will promote effective multidisciplinary team-working, in particular between paediatricians, obstetricians, midwives and neonatal staff. These measures should include, but not be limited to, joint training sessions, clinical, policy and management meetings and staff development activities. Attendance at designated events must be compulsory within terms of employment.

include; o Delayed Cord Clamping o Skills and Drills training o Development and Implementation of Never Event Action Plans as

a multi-professional team o Perinatal Meeting o Divisional Governance Meeting o Labour ward forum o Quality Improvement Forum o Human Factors Training o Risk team

6. University Hospitals of Morecambe Bay NHS Foundation Trust should draw up a protocol for risk assessment in maternity services, setting out clearly: who should be offered the option of delivery at a consultant led unit and who should not; who will carry out this assessment against which criteria; and how this will be discussed with pregnant women and families. The protocol should

Green - Booking guidelines clearly identify mothers where delivery is recommended in the consultant unit. This is based on the booking appointment by the community midwives where a risk assessment is completed and is subject to an on-going review. In such cases, mothers are either reviewed in the consultant antenatal clinic or an electronic request is sent for an opinion.

- Where mothers are advised to deliver in the consultant unit but decline, this decision is documented in the maternity notes and where applicable the Supervisor of Midwives is informed. There is a seamless transfer of care from the community Birthing Centres to acute hospital.

- There is a transfer of labour protocol which is checked on a biannual basis.







involve all relevant staff groups, including midwives, paediatricians, obstetricians and those in the receiving units within the region. The Trust should ensure that individual decisions on delivery are clearly recorded as part of the plan of care, including what risk factors may trigger escalation of care, and that all Trust staff are aware that they should not vary decisions without a documented risk assessment.

7. University Hospitals of Morecambe Bay NHS Foundation Trust NHS Foundation Trusts should audit the operation of maternity and paediatric services, to ensure that they follow risk assessment protocols on place of delivery, transfers and management of care, and that effective multidisciplinary care operates without inflexible demarcations between professional groups.

Amber - All services sit within the W&C divisional board/governance arrangements that reviews the operation of the maternity and neonatal/paediatric services. There is a quarterly governance report.

- Pathway extended into neonatal care by planning for forthcoming deliveries and antenatal consults for high risk babies.

- Daily multidisciplinary labour ward board reviews are in place and ward round including obstetric, midwifery, neonatal and anaesthetic and theatre staff.

- There is a formal review and audit of all transfers in labour. - All maternal critical care patients are reviewed daily by Consultant

obstetrician and anaesthetist in ITU/HDU.







8. University Hospitals of Morecambe Bay NHS Foundation Trust NHS Foundation Trusts should identify a recruitment and retention strategy aimed at achieving a balanced and sustainable workforce with the requisite skills and experience. This should include, but not be limited to, seeking links with one or more other centre(s) to encourage development of specialist and/or academic practice whilst offering opportunities in generalist practice in the Trust; in addition, opportunities for flexible working to maximise the advantages of close proximity to South Lakeland should be sought.

Green - Close links are maintained with the SW Neonatal ODN and the obstetricians have close links with the Perinatal Medicine service in Bristol.

- The ANNP positions are proving hard to recruit to but there are opportunities for training from within establishment and adequate mitigating plans while waiting for this to be completed.

- Introduction of rotational posts within the maternity services with central recruitment.

- Support the retention of staff.

9. University Hospitals of Morecambe Bay NHS Foundation Trust NHS Foundation Trusts should identify an approach to developing better joint working between its main hospital sites, including the development and operation of common policies, systems and standards. Whilst we

Green - There are joint protocols across the service which includes the Birthing Centres. There is an annual review of staffing levels which will include maternity, gynaecology and paediatric services.

- There are flexible working arrangements in place to mobilise staff in times of high activity. The maternity service is managed as a whole team using a staffing escalation policy.







do not believe that the introduction of extensive split-site responsibilities for clinical staff will do much other than lead to time wasted in travelling, we do consider that, as part of this approach, flexibility should be built into working responsibilities to provide temporary solutions to short-term staffing problems.

10. University Hospitals of Morecambe Bay NHS Foundation Trust NHS Foundation Trusts should seek to forge links with a partner Trust, so that both can benefit from opportunities for learning, mentoring, secondment, staff development and sharing approaches to problems. This arrangement is promoted and sometimes facilitated by Monitor as ‘buddying’ and we endorse the approach under these circumstances.

Green - The RUH actively supports learning mentoring arrangements between organisations and although there are no formal partner arrangement, there is close working relations with the multi-professional Maternity Services Liaison Committee.

- There remains links with GWH the previous provider to provider of maternity services.

11. University Hospitals of Morecambe Bay NHS Foundation Trust NHS Foundation

Green - Reviewing the awareness within the Women and Children’s Division includes;

o Incident reporting is included in the Trust and local Induction. Author : Vicky Tinsley, Head of Nursing and Midwifery Document Approved by: Helen Blanchard, Director of Nursing & Midwifery






Trusts should identify and implement a programme to raise awareness of incident reporting, including requirements, benefits and processes. The Trust should also review its policy of openness and honesty in line with the duty of candour of professional staff, and incorporate into the programme compliance with the refreshed policy.

o Patient safety training is included in maternity services mandatory training.

o Patient safety Staff newsletter embedded within maternity services. o Patient safety Staff newsletter initiated and circulated in NICU. o Plan to develop patient safety staff newsletter for paediatric and

gynaecology services. o All incidents/DATIX are reviewed by the multi-professional senior

management team - Duty of candour has been discussed at safety briefings. Duty of candour

discussed at divisional sisters meetings and relevance of meeting requirement and documentation.

o Duty of candour recorded on Divisional contact register. o Duty of candour reviewed at all professional review meetings. o Increase divisional awareness further via ward and unit meetings o The Trust has a Duty of Candour Lead professional and Duty of

Candour policy which provides guidance and consistency 12. University Hospitals of Morecambe Bay

NHS Foundation Trust should review the structures, processes and staff involved in investigating incidents, carrying out root cause analyses, reporting results and disseminating learning from incidents, identifying any residual conflicts of interest and requirements for additional training. The Trust should ensure that robust

Green - The Trust and women and children’s division utilises an agreed process for reviewing incidents.

- The Trust and women and children’s division utilises an agreed root cause analysis toolkit, as recommended by the National Patient safety Agency when undertaking root cause analysis investigations.

- Staff are independent of any serious incidents undertake the root cause analysis

- Root cause analysis investigations are undertaken by staff with specific root cause analysis training. o Findings from root cause analysis investigations are escalated to the







documentation is used, based on a recognised system, and that Board reports include details of how services have been improved in response. The review should include the provision of appropriate arrangements for staff debriefing and support following a serious incident.

Board of Directors via the Quality report o The Trust’s Management Board are notified of SIs via the upward

reporting form the Trust’s Operational Governance Committee. o Learning from incidents is via divisional and speciality governance

dissemination, audit meetings, perinatal meetings, reporting at unit and ward meetings and quarterly newsletters.

o Staff support is assessed and addressed at the SI professional review meetings. The Trust offers EAP and TRiM services and staff directly involved in serious incidents are offered these services.

o There is a multi-professional risk team 13. University Hospitals of Morecambe Bay

NHS Foundation Trust NHS Foundation Trusts should review the structures, processes and staff involved in responding to complaints, and introduces measures to promote the use of complaints as a source of improvement and reduce defensive ‘closed’ responses to complainants. The Trust should increase public and patient involvement in resolving complaints, in the case of maternity services through the Maternity Services Liaison Committee.

Green - The complaints and investigations have a names professional to support them through the investigation process. All complaints response letters are reviewed by a divisional senior manager and final sign off by a member of the executive team.

- Complaint meetings are offered to encourage face to face dialogue with complainants and the clinical teams, this support greater patient and carer involvement. All complaints are recorded on Datix and monitored/audited through this system.

- Complaints are brought to the Speciality Governance meeting to share learning and themes from complains are compiled into the monthly Clinical Governance report.

- Learning from complaints is actively sort.







14. University Hospitals of Morecambe Bay NHS Foundation Trust should review arrangements for clinical leadership in obstetrics, paediatrics and midwifery, to ensure that the right people are in place with appropriate skills and support. The Trust has implemented change at executive level, but this needs to be carried through to the levels below. All staff with defined responsibilities for clinical leadership should show evidence of attendance at appropriate training and development events.

Green - Each service is led by a consultant clinical lead, lead manager and matron. All are formally appointed with supporting job descriptions, job plans and formal appraisals.

- The training needs of all professionals is actively reviewed through a system of 1:1 meetings and formal appraisals.

15. University Hospitals of Morecambe Bay NHS Foundation Trust should continue to prioritise the work commenced in response to the review of governance systems already carried out, including clinical governance, so that the Board has adequate assurance of the quality of care provided by the Trust’s services. This work is already underway with the facilitation of

Green - The Trust has a robust governance reporting structure: o Speciality governance groups report to the divisional governance

group. o Divisional governance group report to the operational governance

committee. o Operational governance committee escalates assurance to the

Trust Board. o Divisional governance groups also report to the clinical governance

Committee and audit committee. Both of these groups escalate assurance to the Trust board.







Monitor, and we would not seek to vary or add to it, which would serve only to detract from implementation. However it is, recommended that a full audit of implementation be undertaken before this is signed off as completed.

16. As part of the governance systems work, University Hospitals of Morecambe Bay NHS Foundation Trust should ensure that middle managers, senior managers and non-executives have the requisite clarity over roles and responsibilities in relation to quality, and it should provide appropriate guidance and where necessary training.

Green - The overarching philosophy of the division is that quality is core business to all roles. There are defined responsibilities within the divisional governance and quality improvement structures and the benefit of having a Divisional Lead for Transformation who helps to identify training needs and to support other members of the management team.

- There are Patient Safety Walk About by the Executive Team on a regular basis.

- A designated W&C Quality Improvement Forum supports staff in taking quality improvement projects forward

- There is a Divisional representation at all key Trust meeting including Quality Board and the Clinical Outcomes Group.

17. University Hospitals of Morecambe Bay NHS Foundation Trust should identify options, with a view to implementation as soon as practicable, to improve the physical environment of the delivery suite at Furness General Hospital,

Green - The Maternity Service successfully bid for funding to upgrade the Delivery Suite and Mary Ward in 2014 and development of Bereavement Suite in 2015. The delivery room at Trowbridge Birthing Centre was also up-graded in 2015.







including particularly access to operating theatres, an improved ability to observe and respond to all women in labour and en suite facilities; arrangements for post-operative care of women also need to be reviewed.

18. All of the previous recommendations should be implemented with the involvement of Clinical Commissioning Groups and where necessary the University Hospitals of Morecambe Bay.

Not appropriate to comment

ADDITIONAL LEARNING POINTS IDENTIFIED IN THE REPORT

1. There was evidence of a lack of basic understanding of the processes of labour by both midwifery and medical staff. There were frequent examples of staff ignoring the whole clinical picture of the woman (including pre-existing risk factors) and her baby, and only reacting to events in isolation. A lack of clinical risk assessment and planning for high-risk

Green - Clear pathways for high risk pregnancies following detailed risk assessment at booking.

- Pathways are already in place for abnormal first trimester screening results

- Pathways also initiated at anomaly scanning, which has recently been audited.

- Multi-professional “care in labour protocol” which sets out the care pathway for labouring women.

- Pathway extended into neonatal care by planning for forthcoming deliveries and antenatal consults for high risk babies.







obstetric patients was an overarching theme. Despite its relative isolation, this was most prevalent in FGH.

Learning Point –Clinical risk assessment and effective planning are crucial if patient harm is to be avoided.

- Daily multidisciplinary labour ward board review and ward round including obstetric, midwifery, neonatal and anaesthetic and theatre staff

- All maternal critical care patients reviewed daily by Consultant obstetrician and anaesthetist.

2. Most importantly, there is evidence of poor interdisciplinary working relations and substandard care. The failure of obstetricians and paediatricians to communicate in a professional way on the planning and delivery of high-risk patients is unacceptable. Similarly, the reluctance of midwives and obstetricians to share responsibility for the care of high-risk pregnant women is denying patients their rights to the best care.

Learning Point – The importance of multi professional working cannot be over emphases for effective safe care.

Green - Clear pathways involving seamless care from in utero to ex utero. - Examples of recent joint innovation such as neonatal SBAR and delayed

cord clamping. - Joint guideline development - PROMPT training – planned that neonatal nursing and medical staff to

attend - Labour ward forum is a multi-professional Team Meeting - Support neonatal nursing a medical staff in attendance at MD PROMPT

training to discuss and simulate effective communication and team working.







3. As a consequence of the serial restructuring by the Trust, maternity and neonatal services had their management arrangements changed six times during the period covered by this Investigation. As a result of this managerial instability, there is evidence that lines of responsibility and accountability were blurred, many posts were combined and in some cases became unworkable, individuals were given management posts in maternity and neonatal services without any knowledge or experience of these services, and the focus was on operational objectives such as finance and waiting times rather than governance and quality of service.

Learning point- Managerial stability to essential for safe and effective maternity care

Amber - The Women and Children’s Divisional Board was formed with the acquisition of Maternity Services in June 2014. There has been a period of stabilisation and establishment of safe business as usual. There is an emerging plan for how to develop the service over the next 3 to 5 years. Key to this has been the development of integrated governance structures across the division including the neonatal service and maternity.

- There has been successful implementation of a new Maternity IT system to align with the rest of the hospital.

- The next steps include a review of the community units with a view to promoting best practice in a consistent way in all localities and to improve the pathways across the community service and clear staffing links with CDS. There is a review of the community unit’s environment and in line with this a review of the future physical footprint and key adjacencies within the RUH. There is a commitment to the principles outlined in the NICE guidance on Place of Birth.

- Other work streams include a review of Mary Ward and PAW and the development of Transitional Care for neonates.

- Key to longer term planning is confirmation of the maternity contract being on a longer term basis than just 3 years.

-





Status

Red Cause for concern identified. Evidence available at the time of the assessment shows the recommendation is not met.

Amber Moderate concern identified. Evidence available at the time of the assessment shows the recommendation is partially met.

Green Evidence available at the time of assessment shows the recommendation is met.




Appendix B: RUH self-assessment against the Morecambe Bay recommendations

Recommendation Ref No

2,3,4

Recommendation RUH to review having training and competencies for all obstetric, paediatric, midwifery and neonatal medical staff.

Recommendation RAG rating

Amber

Action No

Actions required (specify “None”, if none required)

Action by date

Person responsible

(Name and grade)

Monitoring Group

Status Comments/action status

(Provide examples of action in progress, changes in practices etc)

Examples of how actions taken have led to improved performance

1 To set up a short term task and finish group to review training and competencies

01/09/2015 Practise Development Midwife

Divisional Governance Lead

Divisional Board

Green This group will run for 6 months from September 2015 to February 2016.





Action No


Action by date

Person responsible

(Name and grade)

Monitoring Group




2 To develop a divisional training and competency plan and appropriate funding

28/02/2016 Practise Development Midwife

Divisional Governance Lead

Divisional Board

Green


7

Recommendation NHS Foundation Trusts should audit the operation of maternity and paediatric services, to ensure that they follow risk assessment protocols on place of delivery, transfers and management of care, and that effective multidisciplinary care operates without inflexible demarcations between professional groups.


Green





Action No


Action by date

Person responsible

(Name and grade)

Monitoring Group




1 To audit the operation of maternity and paediatric services to ensure they follow risk assessment protocols on place of delivery, transfer and management of care.

30/10/2015 Head of Division

Head of Risk and Assurance/Lead for Quality Assurance/ Clinical Audit Midwife

Divisional Management Board

Green To be added to the Trust Clinical Audit Programme.





Action No


Action by date

Person responsible

(Name and grade)

Monitoring Group




1 Deliver on improvements outlined in original Maternity tender

01/09/2015 Divisional Management

Maternity Contract Review Group

Green New group will be set up in September 2015 to review progress made with implementing the contract and agree actions going forward

2 Agree plan on future tendering process with Chief Executive


Divisional Board

Green Actions following this meeting will be taken to the maternity contract review group


3

Recommendation Clear vision/strategy for Maternity and Neonatal Services


Amber





3 Develop 5 year vision for W&C Division


Divisional Board

Green Future footprint work underway and ‘vision for the future’ workshop being held with Maternity on 18th May 2015




report to: public board of directors agenda item: 10 date

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